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ENVIRONMENTAL HEALTH <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INF MATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOROF THE OPERTY AND/OR FACILITY <br />LOCATED AT <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />TO RELEASE ANY AND ALL A ALYTICAL INF ATIO TO SAN JOAQUIN CO ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT S AVAILABLE A T TH SAME <br />TIME ITIS PROVIDT TO ME O MY REPRESENTATI <br />BUSINESS NAME: <br />OWNER: <br />ADDRESS: <br />PHONE: ( 1 <br />EH 23 046 (Revised 02/20/09) <br />(IfApplicable) <br />Print) <br />• Signature) <br />(Mailing Address) <br />(City) <br />(Date) <br />5 <br />(Title) <br />(State) (Zip Code) <br />